A 70-year-old client in a nursing home is found wandering in the hall and has a new onset confusion. Which action should the registered nurse implement ́ first?

Notify the client's family to come visit client

Instruct the client return to their room

Ask the unlicensed assistive personnel (UAP) to push fluids

Assess the client's lung fields and temperature

Answer and Explanation

The Correct Answer is D

A. Notifying the client's family may be appropriate after assessing the client and identifying the cause of the confusion. However, it is not the first action, as the priority is to determine if the confusion is due to a medical condition requiring immediate attention.

B. Instructing the client to return to their room addresses the wandering behavior but does not address the underlying cause of the new onset confusion. Without further assessment, this action may delay necessary interventions.

C. Asking the UAP to push fluids assumes that dehydration is the cause of the confusion without evidence. While encouraging hydration may be beneficial later, it is essential first to assess for other potential causes, such as infection or hypoxia.

D. Assessing the client's lung fields and temperature is the first priority because new onset confusion in an older adult is often a symptom of an underlying medical issue, such as infection (e.g., pneumonia or urinary tract infection) or hypoxia. Early assessment helps identify the cause and guide appropriate interventions.

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Correct Answer is A

Explanation

A. Administering pain medication is the priority action in this scenario. The patient is experiencing significant post-surgical pain, which can impair their ability to breathe deeply and effectively. Addressing pain will improve comfort and facilitate better respiratory effort.

B. Notifying the healthcare provider immediately is not warranted based on the current findings. The amount of drainage (50 mL) is within expected limits for the first hour after surgery, and fluctuation in the water seal chamber indicates the chest tube is functioning properly.

C. Repositioning the patient to the unaffected side may help with comfort but is not the most appropriate action to address the pain or improve respiratory status in this situation.

D. Documenting the findings and continuing to monitor the drain is important but does not address the patient’s immediate need for pain relief.

A. Cough with clear sputum B. Oxygen saturation of 95% C. Respiratory rate of 28 breaths per minute D. Mild dyspnea with activity

Correct Answer is C

Explanation

A. A cough with clear sputum is a common symptom in COPD and does not warrant immediate intervention unless there is a change in the color, consistency, or amount of sputum, which could indicate infection.

B. An oxygen saturation of 95% is within normal limits for most individuals and is often acceptable for clients with COPD, as their target saturation is usually lower (88-92%) to avoid suppressing their hypoxic drive.

C. A respiratory rate of 28 breaths per minute indicates tachypnea, which suggests respiratory distress or worsening of the client’s condition. Immediate assessment and intervention are needed to prevent further deterioration.

D. Mild dyspnea with activity is a common symptom in clients with end-stage COPD and does not require immediate intervention unless it becomes severe or unrelieved with rest.

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A 70-year-old client in a nursing home is found wandering in the hall and has a new onset confusion. Which action should the registered nurse implement ́ first?

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Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

The nurse is caring for a client diagnosed with end-stage chronic obstructive pulmonary disease (COPD). Which of the following data warrants immediate intervention by the nurse?

Correct Answer is C

Explanation

A patient hospitalized with chronic obstructive pulmonary disease (COPD) is being discharged home on oxygen therapy. Which instruction should the nurse include in the discharge teaching?

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Which assessment data would warrant immediate intervention by the nurse?

A 70-year-old client in a nursing home is found wandering in the hall and has a new onset confusion. Which action should the registered nurse implement ́ first?

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